Evaluation of a pamphlet on visceral leishmaniasis …healthcare workers, the majority (89.0% of...

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ARTIGO ARTICLE 606 Cad. Saúde Pública, Rio de Janeiro, 21(2):606-621, mar-abr, 2005 Evaluation of a pamphlet on visceral leishmaniasis as a tool for providing disease information to healthcare professionals and laypersons Avaliação de um folheto sobre leishmaniose visceral como instrumento para fornecer informações a profissionais de saúde e leigos 1 Centro de Pesquisas René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, Brazil. Correspondence Z. M. P. Luz Laboratório de Pesquisa Clínica, Centro de Referência em Leishmaniose, Centro de Pesquisas René Rachou, Fundação Oswaldo Cruz. Av. Augusto de Lima 1715, Belo Horizonte, MG 30190-002, Brasil. [email protected] Zélia Maria Profeta da Luz 1 Virgínia Schall 1 Ana Rabello 1 Abstract Although educational materials are frequently produced and used as part of control programs in Brazil, little is known about the efficacy of this type of information. This study evaluated the potential for disseminating information on visceral leishmaniasis using a pamphlet. The sample consisted of 551 healthcare workers and 379 laypeople from a metropolitan area located in southeast Brazil. Both before and after read- ing the pamphlet, subjects completed a multi- ple-choice questionnaire. Overall baseline knowl- edge of the disease was estimated by the propor- tion of correct answers before reading the pam- phlet. Although specific knowledge among zoono- sis control workers was higher (90.0% on aver- age), overall baseline knowledge of the disease varied from 45.0% to 77.0%. After reading the pamphlet, the levels increased to 71.0% and 96.0%, respectively. Before reading, the lowest proportion of correct answers in all groups re- lated to the disease symptoms. Analysis of incor- rect answers showed that visceral leishmaniasis is mainly confused with leptospirosis. The in- creased proportion of correct answers after reading the pamphlet is evidence of its potential as an educational tool. Pamphlets; Visceral Leishmaniasis; Question- naires; Health Personnel Introduction In Brazil, visceral leishmaniasis (VL), caused by Leishmania (Leishmania chagasi), is the most severe of the leishmaniases and can be fatal if untreated. In this country, as elsewhere in Latin America, increasing migration and urbaniza- tion have contributed greatly to the rise of VL as a major public health problem 1,2 . Although the disease was historically found in rural ar- eas, its epidemiological pattern has changed in the last 20 years. In some previously non-en- demic large cities, VL incidence has been in- creasing 3,4,5 . The Greater Metropolitan Area of Belo Hor- izonte in the State of Minas Gerais in Southeast Brazil has a population of 4,606,318 (http:// www.datasus.gov.br, accessed on 21/Mar/2003). Since the first reported case in 1989, VL cases have increased exponentially. Simultaneously, a geographic expansion of VL within Greater Metropolitan Belo Horizonte has been observed. As of 2002, 51.0% of the municipalities com- prising this Greater Metropolitan Area report- ed autochthonous VL cases. Death from VL in Greater Metropolitan Belo Horizonte is com- mon; the case-fatality rate is approximately 10.0%. The low number of qualified healthcare professionals capable of making an early diag- nosis and the resulting lack of prompt treat- ment contribute to this elevated case-fatality rate 5 .

Transcript of Evaluation of a pamphlet on visceral leishmaniasis …healthcare workers, the majority (89.0% of...

Page 1: Evaluation of a pamphlet on visceral leishmaniasis …healthcare workers, the majority (89.0% of com-munity healthcare workers, 46.0% of zoonosis control agents, and 55.0% of nurses)

ARTIGO ARTICLE606

Cad. Saúde Pública, Rio de Janeiro, 21(2):606-621, mar-abr, 2005

Evaluation of a pamphlet on visceralleishmaniasis as a tool for providing disease information to healthcare professionals and laypersons

Avaliação de um folheto sobre leishmaniosevisceral como instrumento para fornecerinformações a profissionais de saúde e leigos

1 Centro de Pesquisas RenéRachou, Fundação OswaldoCruz, Belo Horizonte, Brazil.

CorrespondenceZ. M. P. LuzLaboratório de PesquisaClínica, Centro de Referênciaem Leishmaniose, Centro de Pesquisas René Rachou,Fundação Oswaldo Cruz.Av. Augusto de Lima 1715,Belo Horizonte, MG 30190-002, [email protected]

Zélia Maria Profeta da Luz 1

Virgínia Schall 1

Ana Rabello 1

Abstract

Although educational materials are frequentlyproduced and used as part of control programsin Brazil, little is known about the efficacy ofthis type of information. This study evaluatedthe potential for disseminating information onvisceral leishmaniasis using a pamphlet. Thesample consisted of 551 healthcare workers and379 laypeople from a metropolitan area locatedin southeast Brazil. Both before and after read-ing the pamphlet, subjects completed a multi-ple-choice questionnaire. Overall baseline knowl-edge of the disease was estimated by the propor-tion of correct answers before reading the pam-phlet. Although specific knowledge among zoono-sis control workers was higher (90.0% on aver-age), overall baseline knowledge of the diseasevaried from 45.0% to 77.0%. After reading thepamphlet, the levels increased to 71.0% and96.0%, respectively. Before reading, the lowestproportion of correct answers in all groups re-lated to the disease symptoms. Analysis of incor-rect answers showed that visceral leishmaniasisis mainly confused with leptospirosis. The in-creased proportion of correct answers afterreading the pamphlet is evidence of its potentialas an educational tool.

Pamphlets; Visceral Leishmaniasis; Question-naires; Health Personnel

Introduction

In Brazil, visceral leishmaniasis (VL), caused byLeishmania (Leishmania chagasi), is the mostsevere of the leishmaniases and can be fatal ifuntreated. In this country, as elsewhere in LatinAmerica, increasing migration and urbaniza-tion have contributed greatly to the rise of VLas a major public health problem 1,2. Althoughthe disease was historically found in rural ar-eas, its epidemiological pattern has changed inthe last 20 years. In some previously non-en-demic large cities, VL incidence has been in-creasing 3,4,5.

The Greater Metropolitan Area of Belo Hor-izonte in the State of Minas Gerais in SoutheastBrazil has a population of 4,606,318 (http://www.datasus.gov.br, accessed on 21/Mar/2003).Since the first reported case in 1989, VL caseshave increased exponentially. Simultaneously,a geographic expansion of VL within GreaterMetropolitan Belo Horizonte has been observed.As of 2002, 51.0% of the municipalities com-prising this Greater Metropolitan Area report-ed autochthonous VL cases. Death from VL inGreater Metropolitan Belo Horizonte is com-mon; the case-fatality rate is approximately10.0%. The low number of qualified healthcareprofessionals capable of making an early diag-nosis and the resulting lack of prompt treat-ment contribute to this elevated case-fatalityrate 5.

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The leishmaniasis control program followsa limited and costly protocol focusing on treat-ment of human cases, intra-domiciliary appli-cation of insecticide, and sacrificing seroposi-tive dogs. Awareness-raising strategies con-cerning the disease are needed at all levels ofthe community. Dissemination of VL informa-tion in an educational campaign using infor-mative/educational materials such as hand-books, booklets, and pamphlets may be a valu-able tool as an adjunct to healthcare serviceprotocols and control programs. Nonetheless,in order to serve as effective teaching tools,these materials must be preceded by scientificinvestigation and produced within well-definedcriteria. It is crucial that they provide tangibleconcepts which are presented with the targetpopulation’s cognitive potential in mind 6.

Although educational materials are frequent-ly produced and used as part of control pro-grams in Brazil, very little is known about theeffectiveness of this kind of information. Thelow quality of available leishmaniasis informa-tion in Brazil (especially in booklets and pam-phlets) has been discussed by Luz et al. 7. Theseauthors concluded that the 18 publications an-alyzed generally failed to provide bibliographiesor properly identify the target readers or objec-tives. Moreover, the lack of appropriate illus-trations and the presence of conceptual errorsclearly undermined the information’s impact.

This study presents an evaluation of knowl-edge among healthcare workers and laypeopleboth before and after reading an independent-ly prepared informative pamphlet on VL.

Methodology

Study area

The study was carried out in Belo Horizonte, acity of 2,228,065 inhabitants and the capital ofMinas Gerais State, and two other municipali-ties in Greater Metropolitan Belo Horizontewithin approximately 30km of the capital: Ri-beirão das Neves and Santa Luzia, with 278,572and 199,450 inhabitants, respectively (http://www.datasus.gov.br, accessed on 21/Mar/2003).In 2002, the number of reported cases (and thecase-fatality rate) of VL were 75 (11.0%) in BeloHorizonte, 21 (4.8%) in Ribeirão das Neves, and22 (4.5%) in Santa Luzia. Figure 1 shows the loca-tion of these municipalities and the geographicalexpansion of VL in the region from 1989 to 2002.

The pamphlet

Figure 2 shows the pamphlet’s design. The ma-terial was developed by a team of professionalsfrom the Leishmaniasis Reference Center at theRené Rachou Research Center, Oswaldo CruzFoundation, in partnership with a group of sixhealthcare workers (involved in surveillanceactivities) from various municipalities in GreaterMetropolitan Belo Horizonte. In an attempt toavoid the errors and inadequacies generallyfound in this kind of material, the pamphletwas based on the results of our previous as-sessment of informative materials on leishma-niasis 7. The population’s prior information,and especially that of patients under treatmentfor VL at the Leishmaniasis Research Center,was also considered. The pamphlet highlights

Figure 1

A. Map of Brazil showing Greater Metropolitan Belo Horizonte (insert) in the State

of Minas Gerais. B. Geographic expansion (light-gray area) of visceral leishmaniasis

in the region from 1989 to 2002.

3 2

1

1989-1994 1995-1997 1997-2002

1 – Belo Horizonte2 – Santa Luzia3 – Ribeirão das Neves

Figure 1a

Figure 1b

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Figure 2

Contents and illustrations of the visceral leishmaniasis pamphlet.

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the main aspects of the disease, using accessi-ble language and clear illustrations. The con-tents are divided into several topics, accompa-nied by short texts. Topics include leishmania-sis transmission mechanisms, the most evidentsymptoms, control measures, and instructionsfor seeking medical assistance.

Questionnaires

An anonymous, seven-question, multiple-choicequestionnaire was used (Table 1), designed ac-cording to the general steps for questionnaires8. The concerns and recommendations of expe-rienced local epidemiological-surveillance andhealth-education coordinators were also takeninto account. In order to make the reasoningsimple and straightforward, the questionnaireincluded all topics covered in the pamphlet,and the questions were listed in the same orderin which the topics appear in the material. Thesame questionnaire was given to all partici-pants both before and immediately after read-ing the pamphlet. General data such as age, gen-der, occupation, and schooling were collected.A group of 220 healthcare workers and stu-dents (from Belo Horizonte and Santa Luzia)who were not participating in the study gradedthe questionnaire. Scoring was based on levelof clarity, considering the ratio of incorrect an-swers, non-responses, and multiple answers tothe number of correct answers.

Studied groups

Nine hundred and twenty subjects were in-formed about the general objectives of the re-search and invited to participate. Two groupswere studied. Group 1 consisted of healthcareworkers: either community healthcare workers(n = 309) belonging to the Family Health Pro-gram (sponsored by the Brazilian Ministry ofHealth), zoonosis control agents (n = 190) (tech-nical personnel involved in control activities),or nursing personnel (n = 52). Of the 52 nurs-ing professionals, 15 (29.0%) were registerednurses with university degrees, while the other37 (71.0%) had completed a technical trainingcourse as nurse technicians. Group 2 consistedof users of healthcare services (n = 30), teach-ers (n = 126), and students from public elemen-tary and high schools (n = 223). Previously stan-dardized procedures were adopted to avoidbias in the results. All subjects participated vol-untarily. The study lasted from June to Decem-ber 2002.

Table 1

Questionnaire given before and after reading the pamphlet.

Circle your answer for the following questions

1) Visceral leishmaniasis is known as...

a) Leprosy

b) Malaria

c) Dengue

d) Kala-azar

e) Leptospirosis

2) Visceral leishmaniasis is transmitted...

a) Through dog bites

b) Through the bite of the Aedes aegypti mosquito

c) Through the bite of the phlebotomus sandfly

d) Through mouse urine

3) The symptoms of visceral leishmaniasis in humans are...

a) Fever for several days, weight loss and coughing

b) Skin lesions

c) Fever, body aches, headache, conjunctivitis

d) Increase fingernail and hair growth

4) Visceral leishmaniasis is a disease that requires...

a) That people and dogs be vacinated

b) No treatment

c) Immediate treatment

d) Treatment only in the later phase of the disease

5) What you need to do when you perceive the symptoms of the disease?

a) Stay in bed and drink a lot of liquid

b) See a doctor

c) Talk to a pharmacist

d) Take fever and pain medication

6) How can you help with the control measures?

a) Don’t eat raw meat

b) Cover the water tank and don’t let any water stagnate

c) Keep the area outside the dwelling clean

d) Use shoes and gloves when dealing with the grease trap

e) Stay away from contaminated water

7) How is the disease controlled?

a) By eliminating stagnant water, vaccinating of dogs and treating patients

b) By eliminating triatominae and snails and treating patients

c) By eliminating dogs and treating patients

d) By eliminating scorpions and rats and treating patients

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Data analysis

Answers from the questionnaires and all par-ticipant data were analyzed with Epi Info 6.0.For comparison of the proportion of correctanswers, the chi-square test with a 0.05 level ofsignificance was used.

Results

Potential for transmission of knowledge

The study subjects from Belo Horizonte includ-ed 309 community healthcare workers, 190zoonosis control agents, 126 teachers, 223 pub-lic elementary and high school students, and30 users of healthcare services. The city of BeloHorizonte is administratively divided into nineregions, and the users of healthcare serviceswere all from the same region. The other sub-jects were from seven different regions. Nurseswere all from Ribeirão das Neves. Approximate-ly 60.0% of participants were female healthcareprofessionals. Table 2 shows the frequency andproportions of all samples evaluated, as well asthe participants’ occupation and gender. Amonghealthcare workers, the majority (89.0% of com-munity healthcare workers, 46.0% of zoonosiscontrol agents, and 55.0% of nurses) had workedat the same job for 1 to 5 years (mean = 2 years).Median age of public elementary and high schoolstudents was 16 years, ranging from 13 to 41.Thirty (14.0%) and 129 (58.0%) of the studentswere 6th and 8th graders, respectively. Another61 were high school freshmen and sophomores,32 (14.0%) and 29 (13.0%), respectively. Three(1.4%) of the students did not inform their gradelevel. Among the teachers, 23 (18.0%) were sci-ence teachers. Users of healthcare service con-

sisted mainly of women (87.0%), with a medianage of 48 years (range 21-73), and 52.0% werehousewives, while the others had various occu-pations such as commercial workers, seam-stresses, providers of general services, etc.

Baseline knowledge of the disease as esti-mated by the proportion of correct answers be-fore reading the pamphlet varied considerably.With the exception of zoonosis control agents,who averaged 90.0% correct answers, scoresamong healthcare professionals (communityhealthcare workers) varied from 66.0% to 77.0%.Teachers showed a similar profile (64.0% cor-rect). Users of healthcare services and publicelementary and high school students present-ed poor knowledge of the disease (45.0% cor-rect answers). However, reading the pamphletsignificantly improved performance amongcommunity healthcare workers, zoonosis con-trol agents, nurse technicians, teachers and stu-dents, as shown in Table 3. After reading, lowernumbers of non-responses and multiple an-swers were observed.

Before reading the pamphlet, the topic withthe lowest number of correct answers was leish-maniasis symptoms (question 3). This was truefor all groups, including healthcare profession-als (Figures 3 and 4). Concerning need fortreatment and control measures (questions 4and 7, respectively), no differences were ob-served in responses by nurses before and afterreading the pamphlet. Among students, no dif-ferences were observed in question 4. Amonghealthcare users, no statistical differences wereobserved in questions 4, 6, or 7 before or afterreading. On question 5 (what patients are ex-pected to do when they note symptoms of thedisease), high percentages of participants chosethe correct response both before and after read-ing the pamphlet. Incorrect answers were also

Table 2

Occupation and gender of participants in a study on a leishmaniasis pamphlet (n = 930).

Greater Metropolitan Belo Horizonte, Minas Gerais, Brazil.

Categories evaluated Number of % Genderparticipants Female % Male %

Community healthcare workers 309 33.2 269 87.0 40 13.0

Zoonosis control agents 190 20.4 11 6.0 179 94.0

Nursing personnel* 52 5.6 49 94.0 3 6.0

Teachers 126 13.5 110 89.0 14 11.0

Students 223 24.0 112 50.0 110 49.0

Users of healthcare services 30 3.2 26 87.0 4 13.0

* Nursing personnel (registered nurses with university degrees = 15; nurse technicians = 37).

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evaluated for all participant categories. To pre-sent these results, groups were divided into twocategories: healthcare workers in group 1 andparticipants from the other three occupationsin group 2. Average percentages before and af-ter reading the pamphlet are depicted (see Fig-ure 5 for questions 1 to 7). On three questions(4, 6, and 7), reading the pamphlet failed to im-prove the participants’ understanding.

Before reading, VL was mainly confusedwith leptospirosis by both groups. Ten per centof group 1 responded that dogs are the vectorfor leishmaniasis when answering question 1, amisconception related to the disease’s trans-mission. In group 2, a similar proportion thoughtthat VL could be transmitted through mouseurine (question 2). High percentages of respon-dents in both groups believed either that VLsymptoms result from injuries or are similar toclassic dengue symptoms. On the topic of treat-ment (question 4), high percentages in group 1and group 2 chose vaccination as the correctcourse. However, the pamphlet did not addressthis point, and 6.0% of group 1 and 20.0% ofgroup 2 insisted on giving the same incorrectresponse. In addition, nearly 11.0% of group 1thought that treatment is only necessary in thelater phase of the disease. On question 5, lowpercentages of both groups chose incorrect an-swers, and respondents in group 2 continuedto give the same answers after reading. The lasttwo questions (6 and 7) related to control mea-sures. Before and after reading, both groupsthought that VL control measures were thesame as those for dengue.

Discussion

Parasitic and zoonotic diseases have becomeincreasingly prominent due to urban encroach-ment into the natural environment and exten-sive population mobility. Urbanization rateshave multiplied, and this trend has served todraw typically rural diseases into urban areaswhere concentrations of human and vector pop-ulations increase the incidence of infection 9.In Brazil, this increased urbanization is closelyassociated with the sharp increase in VL in ur-ban areas 10. In general, people migrate to largecities in pursuit of better living conditions. How-ever, in the poorer outlying neighborhoodswith various risk factors such as vector pres-ence and inadequate sanitation, transmissioncan easily occur 1. Clinical manifestations of VLvary from disfiguring lesions and scars to death.Severe epidemics with high case-fatality rateswould have serious social and public healthconsequences.

The intrinsic complexity of visceral leish-maniasis, environmental conditions, and thesocio-political and economic context call forprevention and control strategies that involvehealthcare authorities working in close associ-ation with citizens. In addition, such strategiesmust take the population’s knowledge base, be-liefs, perceptions, and practices into account 9.

This paper has attempted tried to outline aframework of knowledge on leishmaniasis inGreater Metropolitan Belo Horizonte, where VLis a relatively new public health problem andmainly affects poor people. Although the num-ber of cases has increased, medical and alliedhealthcare personnel are often unfamiliar withthe disease, and despite control measures theaverage number of fatal cases is relatively high.

Table 3

Average percentage of correct, multiple-answer, or blank questions among individuals before and after reading

the leishmaniasis pamphlet. Greater Metropolitan Belo Horizonte, Minas Gerais, Brazil.

Categories evaluated Correct answers Non-responses or multiple answers

Before After p value Before After

Community healthcare workers 66 92 < 0.001 2 1

Zoonosis control agents 90 96 0.02 9 1

Registered nurses 72 90 0.327 9 1

Nurse technicians 66 89 0.012 13 2

Teachers 64 91 < 0.001 5 1

Students 45 74 < 0.001 4 1

Users of healthcare services 45 71 0.06 16 9

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Figure 3

Percentage of health community workers (a), zoonosis control agents (b), nurse technicians (c), and registered nurses

(d) who correctly answered questions 1 to 7 before and after reading the pamphlet.

% 0

20

40

60

80

100

after

before

7 questions65

*

4321

% 0

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after

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4321

Figure 3a

Health community workers (n = 309)

Figure 3b

Zoonosis control agents (n = 190)

(continues)

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% 0

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Figure 3c (continued)

Nurse technicians (n = 37)

% 0

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after

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*****

Figure 3d

Registered nurses (n = 15)

* No differences.

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Figure 4

Percentage of teachers (a), students (b), and laypeople (c) who correctly answered questions 1 to 7 before

and after reading the pamphlet.

% 0

20

40

60

80

100

after

before

7 questions65

*

4321

% 0

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after

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**

321

Figure 4a

Teachers (n = 126)

Figure 4b

Students (n = 223)

(continues)

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% 0

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****

321

Figure 4c (continued)

Laypeople (n = 30)

* No differences.

In an attempt to improve prevention and con-trol of VL, a pamphlet with basic informationon the disease was developed.

Considering that the primary aim of a ped-agogical message is comprehension, the mes-sage should contain a signal system that is asclear as possible 11. In Brazil, informative ma-terial on leishmaniasis has been distributed inan attempt to reduce the complexity of infor-mation. Unfortunately most of these publica-tions use inappropriate language and containconceptual errors. The effectiveness of their in-formation is thus clearly jeopardized 7. Al-though the pamphlet described in this studycontains technical terms such as Leishmania,sand fly, and parasite, the information is clearenough to be understood. This was evidencedby the fact that although subjects read thepamphlet only once, the majority scored muchhigher after reading than before.

Prior knowledge, measured by the averagepercentage of correct answers in all categories,varied widely and was very poor for students andusers of healthcare services. In the northeasternBrazilian State of Maranhão, which has the coun-try’s second highest incidence of VL (FundaçãoNacional da Saúde. Série histórica de doenças denotificação compulsória. http://www.funasa.gov.br/epi/epi00htm, accessed on 21/Mar/2003),knowledge concerning VL, especially on the sub-jects of prevention and treatment, was minimalamong rural and peripheral urban populations 12.

Our findings related to the baseline knowl-edge possessed by registered nurses, students,and users of healthcare service confirm thoseof previous studies. The question-by-questionanalysis showed that all participants (with theexception of the zoonosis control agents) hadpoor knowledge of leishmaniasis symptoms. Asshown in Figure 5, before reading the pamphlet,nearly 40.0% of both groups confused VL withtegumentary leishmaniasis or dengue. The lowproportion of correct responses among layper-sons could be explained by the confusion aris-ing from multiple answers. However the healthprofessional group, with at least elementaryknowledge of VL, should be expected to inter-pret the options clearly. In this group, onlyzoonosis control agents showed satisfactory fa-miliarity with VL symptoms, with 64.0% of cor-rect answers. This is definite cause for concern.Although all these diseases cause severe dis-ability, special attention should be given to VL,because late diagnosis can be fatal. We specu-late that in Greater Metropolitan Belo Hori-zonte, the high case-fatality rate for VL can beassociated with the lack of qualified profes-sionals 5. Early detection of the disease and re-porting of cases undergoing treatment are fun-damental 13 and will allow control measures tobe taken immediately. Having well-trainedtechnical personnel and efficient delivery sys-tems is important for empowering the currentFamily Health Program, sponsored by the Brazil-

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Figure 5

Average percentage of health professionals (group 1) and others (group 2) who gave incorrect answers

to questions 1 to 7 of the questionnaire, before and after reading the pamphlet.

% 0

5

10

15

20

25

30

leptospirosis

dengue

malaria

leprosy

afterbeforeafterbeforegroup 2group 1

% 0

5

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mouse urine

A. aegypti

dog bite

afterbeforeafterbeforegroup 2group 1

Figure 5a

Question 1)

Figure 5b

Question 2)

(continues)

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% 0

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increased fingernail and hair growth

fever, injury, conjunctivitis

injury

afterbeforeafterbefore group 2group 1

% 0

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35

later treatment

no treatment

vaccination

afterbeforeafterbeforegroup 2group 1

Figure 5c

Question 3)

Figure 5d

Question 4)

(continues)

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% 0

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fever medication

fever and pain medication

rest and liquids

afterbeforeafterbeforegroup 2group 1

% 0

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keep away from contaminated water

keep exterior areas clean

cover the water tank

don't eat raw meat

afterbeforeafterbeforegroup 2group 1

Figure 5e

Question 5)

Figure 5f

Question 6)

(continues)

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% 0

5

10

15

20

25

30

elimination of scorpions and rats

elimination of triatomine and snails

stagnant water and dog vaccination

afterbeforeafterbeforegroup 2group 1

Figure 5g

Question 7)

ian Ministry of Health. In this program, in whichall staff members work as a network, commu-nity healthcare workers identify domestic healthproblems and refer patients to the program co-ordinator, who arranges the necessary care.Consequently, if the staff is well trained, bene-fits will be great for patients in particular andthe program in general. In the questions relat-ed to treatment and control measures, readingthe pamphlet did not change the performanceof the students, users of healthcare service, ornurses. This is an indication of which sectionsof the pamphlet most probably need improve-ment. The use of a closed questionnaire mayalso have elicited correct or even incorrect an-swers. This may have been the case for the highproportion of correct answers to question 5(What should you do when you notice symp-toms of the disease?), in which high percentagesof the participants chose the answer: “See adoctor”. The analysis of incorrect answers be-fore reading showed that students, users ofhealthcare services, and teachers confused VLwith leptospirosis. After reading, even thoughmice were not mentioned in the pamphlet, thisgroup contended that mice are leishmaniasisvectors. The increased confidence in answer-ing the questionnaire after reading the pam-phlet was evidenced by respondents’ low pro-portion of non-responses and multiple an-swers.

In the case of leishmaniasis, disseminationof information has been one of the major tools

used in health education-based control pro-grams. However, the impact of informationtransmitted to the population has not beenevaluated previously by government healthagencies. Six months after access to informa-tion in the pamphlet, we assessed the level ofknowledge retained by 65 students who hadparticipated in this study. Using the same ques-tionnaire, preliminary results showed no dif-ference in the average percentage of correctanswers given by these students six months af-ter in comparison with the questionnaires giv-en immediately after reading the pamphlet. Inaddition, on all topics, the profiles of incorrectanswers were virtually identical (data not shown).

Although survey methods have some limi-tations related to validity and reliability of re-sults, these methodologies are effective toolsfor collecting objective data. This study was anattempt to assess the baseline knowledge of VL,the pamphlet’s capacity to transmit informa-tion, and deficiencies or inadequacies in thematerial. The limited number of studies on thistopic made it difficult to establish parametersfor precise sampling. Nevertheless, these re-sults will provide the basis for further researchon knowledge, attitudes, and practices.

The pamphlet shows great potential, as evi-denced by the high proportion of correct an-swers after reading it. Pamphlets are generallyvaluable informative tools and are useful fordisease control programs, but they should beused within the context of a continuing educa-

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Acknowledgments

The authors would like to thank the epidemiologicalsurveillance and health education coordinators fortheir assistance administering the questionnaire. Wewould also like to thank the Oswaldo Cruz Founda-tion and the Brazilian National Research Council fortheir financial support.

Contributors

The idea for this study was by Z. M. P. Luz, who alsoconducted all the descriptive stages in the methodol-ogy, including the elaboration of the database, dataentry, analysis of the results, and drafting of the arti-cle. V. Schall and A. Rabello participated actively inthe methodological design, discussion of the results,and critical reading of the article.

Resumo

No Brasil, embora materiais educativos sejam fre-qüentemente produzidos como parte de programas decontrole de doenças, muito pouco se sabe a respeito daeficácia desse tipo de informação. Neste estudo, o po-tencial informativo de um folheto sobre a leishmanio-se visceral foi avaliado em amostra de 551 profissio-nais de saúde e 379 indivíduos da população de doismunicípios da Região Metropolitana de Belo Horizonte,Minas Gerais, Brasil. Utilizou-se questionário com setequestões de múltipla escolha, antes e imediatamenteapós a leitura do material. O conhecimento inicial so-bre a doença foi estimado pela proporção de respostascorretas antes da leitura do folheto. Entre os agentes dezoonoses, 90,0% em média responderam corretamenteàs questões, nas outras categorias, a variação foi de45,0% a 77,0%, elevando-se para 71,0% a 96,0%, apósa leitura. A questão com menor percentual de acertos,antes da leitura, foi a relacionada aos sintomas dadoença. Entre as respostas incorretas verificou-se quea leishmaniose visceral é principalmente confundidacom a leptospirose. Após a leitura, o número elevadode respostas corretas mostrou que o potencial de trans-missão da informação do folheto foi adequado.

Folhetos; Leishmaniose Visceral; Questionário; Pessoalde Saúde

Luz ZMP et al.620

Cad. Saúde Pública, Rio de Janeiro, 21(2):606-621, mar-abr, 2005

tional process. For example, an appropriatecombination of information and entertainmentcan increase awareness, which may in turnlead to the creation of alternative solutions andreevaluation of decision-making processes,thereby shedding light on previously over-looked factors 14. In order to generate effectivechanges and strengthen control measures,

health and educational measures should ad-here to well-defined criteria. Such measuresshould also undergo systematic evaluation inorder to measure their impact, and the evalua-tion should be preceded by scientific investiga-tion in order to ensure that the content andpresentation are consistent with the target pop-ulation’s cognitive potential.

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Submitted on 09/Oct/2003Final version resubmitted 07/Jul/2004Approved on 21/Jul/2004